Healthcare Provider Details

I. General information

NPI: 1891867685
Provider Name (Legal Business Name): PHIL PATA II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 BELMONT ST
BELLAIRE OH
43906-1520
US

IV. Provider business mailing address

3235 BELMONT ST
BELLAIRE OH
43906-1520
US

V. Phone/Fax

Practice location:
  • Phone: 740-676-3433
  • Fax: 740-676-3435
Mailing address:
  • Phone: 740-676-3433
  • Fax: 740-676-3435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRTP.021612600-03
License Number StateOH

VIII. Authorized Official

Name: PHILIP PATA
Title or Position: OWNER,PIC,AO
Credential: RPH
Phone: 740-676-3433